Surgical coaching applied to laparoscopic TME for continuous professional development in rectal surgery: proof of concept.

BACKGROUND: Coaching is maturing as a strategy for surgeons' continuous professional development in different types of surgery. Laparoscopic total mesorectal excision (LAP TME) is one of the recognized difficult procedures in colorectal surgery. Aim of this trial is to introduce the surgical coaching as a tool for a continuous technical education of LAP TME for cancer in a consultant surgeon carrier. METHODS: Twelve Italian colorectal surgeons were enrolled as trainees in the AIMS Academy rectal cancer surgical coaching project and attended a face-to-face 90-min surgical coaching on a pre-edited 45-min-long video of a laparoscopic proctectomy according to pre-determined guidelines. At the end of the coaching, all mentors were asked to fill a questionnaire evaluating the trainee's skills. All trainees had to fill a post-coaching questionnaire addressing the appropriateness of the coaching with respect to their actual level. RESULTS: Trainees were more confident in performing the extra-pelvic part of the surgical procedures compared to the intra-pelvic dissection. The most challenging steps according to the trainees were the seminal vesicles identification and the pelvic floor dissection. Mentors found the trainees quite confident in the approach to the vascular structures, lymphadenectomy, stapler utilization and bleeding control. The sharpness and the efficacy of the dissection, the dissection of the surgical planes and the anastomosis fashioning were reported at a lower level of confidence. The higher grade of satisfaction reported by the trainee came from the attention that the mentors demonstrated towards them, from the availability of the mentors to take into consideration the surgical issues raised and from the willingness to apply the suggestions received during their next proctectomies. CONCLUSIONS: The surgical coaching applied to LAP TME should be considered as an innovative tool for continuous professional development.

Ileal pouch-anal anastomosis with fluorescence angiography: a case-matched study.

AIM: An anastomotic leak in ileoanal pouch surgery may lead to pouch failure. Constructing a tension-free ileal pouch-anal anastomosis (IPAA) reduces this risk but can be technically challenging, balancing pouch vascularization with ileal mesenteric length and site of vessel ligation. Fluorescence angiography (FA) may help the clinician make a more balanced judgement. METHODS: Thirty-two patients undergoing minimally invasive completion proctectomy with FA-guided IPAA at two academic centres were matched and compared on a 1:1 basis to a historical group undergoing the same procedure without the use of this technique. RESULTS: Ligation of the ileocolic vessels was safely performed in 15/32 (47%) of FA patients compared with 5/32 (16%) of historical controls. One patient underwent intra-operative IPAA reconstruction after FA detected ischaemia. No anastomotic leak occurred with FA but there was only one in the historical controls (P = 0.31). The postoperative complication rate was similar between the two groups (P = 0.60). CONCLUSION: FA is applicable to IPAA surgery and may help to reduce perfusion-related anastomotic leaks. A prospective randomized trial is warranted.

Poor nutritional status is associated with other geriatric domain impairments and adverse postoperative outcomes in onco-geriatric surgical patients - A multicentre cohort study.

BACKGROUND: Nutritional status (NS), though frequently affected in onco-geriatric patients, is no standard part of a geriatric assessment. The aim of this study was to analyse the association between a preoperatively impaired NS and geriatric domain impairments and adverse postoperative outcomes in onco-geriatric surgical patients. METHODS: 309 patients ≥70 years undergoing surgery for solid tumours were prospectively recruited. Nine screening tools were preoperatively administered as part of a geriatric assessment. NS was based on BMI, weight loss and food intake. Odds ratio's (OR) and 95% confidence intervals (95% CI) were estimated using logistic regression analysis. The occurrence of 30-day adverse postoperative outcomes was recorded. RESULTS: At a median age of 76 years, 107 patients (34.6%) had an impaired NS. Decreased performance status and depression were associated with an impaired NS, when adjusted for tumour characteristics and comorbidities (ORPS>1 3.46; 95% CI 1.56-7.67. ORGDS>5 2.11; 95% CI 1.05-4.26). An impaired NS was an independent predictor for major complications (OR 3.3; 95% CI 1.6-6.8). Ten out of 11 patients who deceased had an impaired NS. CONCLUSION: An impaired NS is prevalent in onco-geriatric patients considered to be fit for surgery. It is associated with decreased performance status and depression. An impaired NS is a predictor for adverse postoperative outcomes. NS should be incorporated in a geriatric assessment.

The assessment and management of older cancer patients: A SIOG surgical task force survey on surgeons' attitudes.

AIM: The Surgical Task Force at SIOG (International Society of Geriatric Oncology) designed this survey to explore the surgical oncologists' approach toward elderly cancer patients. METHODS: A web-based survey was sent to all members of ESSO (European Society of Surgical Oncology) and SSO (Society of Surgical Oncology). RESULTS: Two hundred and fifty-one surgeons responded (11% response rate) with a main interest on breast (62.1%), colorectal (43%) and hepatobiliary (27.4%) surgery. Almost all surgeons (>90%) offer surgery regardless the patient's age; only 48% consider mandatory a preoperative frailty assessment. The American Society of Anesthesiologists (ASA) score, nutritional and performance status are most frequently used as screening tools; only 6.4% surgeons use Comprehensive Geriatric Assessment (CGA) in daily practice and collaboration with geriatricians is low (36.3%). If proven to be effective, the majority of surgeons (71%) is prepared to pre-habilitate patients for up to 4 weeks before surgery. One in two surgeons would not offer an operation to patients with impaired cognitive status; conversely, one in three would proceed to surgery regardless of the patient's cognitive status, if functional capacity is conserved. Quality of life and functional recovery are regarded as the most important endpoints in onco-geriatric surgery. Large "real life" prospective observational studies and randomized controlled trials are demanded. CONCLUSION: Age is not perceived as a limitation to surgery. Screening for frailty is limited. A thorough CGA is seldom used and collaboration with geriatricians is rather uncommon. There is a need for clinical investigations focusing on pre-habilitation and other strategies to achieve better functional recovery.

CDH1 POLYMORPHISMS AND LOW EXPRESSION OF E-CADHERIN AND ß-CATENIN IN COLORECTAL CANCER PATIENTS.

Epithelial-mesenchymal transition (EMT) process has a central role in tumor progression and metastases. Loss of cell-to-cell adhesiveness is a key step in EMT. In particular, E-cadherin and ß-catenin, components of the adherens junctions, play a strategic role. Accumulation of ß-catenin at cytoplasmic level following adherens junctions disruption, induces its translocation into the nucleus, where it binds to members of the TCF/LEF family of transcription factors. In particular, Lymphoid Enhancer-Binding factor 1 (LEF1) product can target genes involved in EMT. The aim of the present study was to evaluate the influence of CDH1 and CTNNB1 genes, coding for E-cadherin and ß-catenin respectively and LEF1 in a sample study of 140 Italian patients affected by colorectal cancer. An association study between four single nucleotide polymorphisms (rs11865026, rs11642413, rs13689, and rs10431923) of CDH1 and the disease did not provide statistically significant results. The gene expression analysis carried out for CDH1, CTNNB1 and LEF1 in 54 paired specimens from 27 patients provided evidence of a reduced expression of the first two in cancer tissues. We believe there may be a sort of cross regulation between the products of these two genes which closely interact in EMT activation and that such hypothesis should be further investigated in a greater number of cases.

Screening for predictors of adverse outcome in onco-geriatric surgical patients: A multicenter prospective cohort study.

AIMS: The aim of this study was to investigate the predictive ability of screening tools regarding the occurrence of major postoperative complications in onco-geriatric surgical patients and to propose a scoring system. METHODS: 328 patients ≥ 70 years undergoing surgery for solid tumors were prospectively recruited. Preoperatively, twelve screening tools were administered. Primary endpoint was the incidence of major complications within 30 days. Odds ratios (OR) and 95% confidence intervals (95% CI) were estimated using logistic regression. A scoring system was derived from multivariate logistic regression analysis. The area under the receiver operating characteristic curve (AUC) was applied to evaluate model performance. RESULTS: At a median age of 76 years, 61 patients (18.6%) experienced major complications. In multivariate analysis, Timed Up and Go (TUG), ASA-classification and Nutritional Risk Screening (NRS) were predictors of major complications (TUG>20 OR 3.1, 95% CI 1.1-8.6; ASA ≥ 3 OR 2.8, 95% CI 1.2-6.3; NRS impaired OR 3.3, 95% CI 1.6-6.8). The scoring system, including TUG, ASA, NRS, gender and type of surgery, showed good accuracy (AUC: 0.81, 95% CI 0.75-0.86). The negative predictive value with a cut-off point >8 was 93.8% and the positive predictive value was 40.3%. CONCLUSIONS: A substantial number of patients experience major postoperative complications. TUG, ASA and NRS are screening tools predictive of the occurrence of major postoperative complications and, together with gender and type of surgery, compose a good scoring system.

Gene expression profile of human colon cancer cells treated with cross-reacting material 197, a diphtheria toxin non-toxic mutant.

Cross-Reacting Material 197 (CRM197) is a diphtheria toxin non-toxic mutant that has shown antitumor activity in mice and humans. It is still unclear whether this anti-tumorigenic effect depends on its strong inflammatory-immunological property, its ability to inhibit heparin-binding epidermal growth factor (HB-EGF), or even its possible weak toxicity. CRM197 is utilized as a specific inhibitor of HB-EGF that competes for the epidermal growth factor receptor (EGFR), overexpressed in colorectal cancer and implicated in its progression. In this study we evaluate the effects of CRM197 on HT-29 human colon cancer cell line behaviour and, for CRM197 recognized ability to inhibit HB-EGF, its possible influence on EGFR activation. In particular, while HT-29 does not show any reduction of viability after CRM197 treatment (MTT modified assay), or changes in cell cycle distribution (flow cytometry), in EGFR localization, phospho-EGFR detected signals (immunohistochemistry) or in morphology (scanning electron microscopy, SEM) they show a change in the gene expression profile by microarray analysis (cDNA microarray SS-H19k8). The overexpression of genes like protein phosphatase 2, catalytic subunit, alpha isozyme (PPP2CA), guanine nucleotide-binding protein G subunit alpha-1(GNAI1) and butyrophilin, subfamily 2, member A1 (BTN2A1) has been confirmed with real-time-qPCR. This is the first study where the CRM197 treatment on HT-29 shows a possible scarce implication of endogenous HB-EGF on EGFR expression and cancer cell development. At the same time, our results show the alteration of a specific and selected number of genes.

[Ectopic breast fibroadenoma. Case report]. / Fibroadenoma in mammella ectopica. Case report.

Among the rare anomalies of the breast development, polythelia is the most common, between 1% and 5% of women and men present supernumerary nipples. Polymastia, usually presenting as ectopic breast tissue without areola-nipple complex, is seen mostly along the milk line, extending from the axilla to the pubic region. Ectopic breast tissue is functionally analogous to mammary gland and it is subjected to the same alterations and diseases, whether benign or malignant, that affect normal breast tissue. We report the case of a 21 years-old female evaluated by the medical staff after founding a solid nodular mass by suspect axillary lymphadenopathy. Differential diagnosis with lymphoma is the major problem in these cases. The mass was removed and the intraoperative histological examination showed fibroadenoma in axillary supernumerary breast. Presence of ectopic breast tissue is a rare condition; development of benign mass or malignant degeneration is possible, but it is very unusual. In case of polymastia diagnosis is simple; in case of isolated nodule, without local inflammation or infection, there are greater difficulties. Ultrasonography is diagnostic in case of breast fibroadenoma, but it might be inadequate in ectopic localizations owing to the shortage of mammary tissue around the mass. Preoperative diagnosis is important to plan an adequate surgical treatment; lumpectomy is indicated in case of benign tissue; in case of malignancy, therapy is based on the standard treatment used for breast cancer (surgery, chemotherapy and radiation therapy).

Can elderly patients with colorectal cancer tolerate planned surgical treatment? A practical approach to a common dilemma.

AIM: Analysing the effectiveness of a surgical procedure is mandatory in every modern health-care system. The aging of the population stresses the need for a good standard of care. This study tests the hypothesis that porthsmouth-physiologic operative severity score for enumeration of morbidity and mortality (P-POSSUM) and colorectal-POSSUM (CR-POSSUM) would be useful clinical auditing tools in colorectal cancer surgery for aged patients. METHOD: One hundred and seventy-seven consecutive patients over 70 years of age underwent emergency or elective surgery from January 2003 to December 2005. Demographic, clinical and surgical information, score systems' prediction, complications and 30-day mortality data were prospectively entered in a comprehensive database. The observed over expected morbidity and mortality rate was calculated. RESULTS: Thirty-day observed mortality was 10.3% (19/177) while P-POSSUM and CR-POSSUM expected mortality were, respectively, 11.21% (P = NS) and 13.08% (P = NS). Overall observed morbidity was 42.7%, P-POSSUM prediction was 59.3% (P = 0.002). Morbidity and mortality data were analysed for specific subgroups of patients (resection and anastomosis/resection and stoma/palliative; emergency/elective). CONCLUSION: P-POSSUM and CR-POSSUM are useful tools to predict mortality in elderly patients. P-POSSUM significantly overestimated the risk of complications. A more accurate tool for preoperative assessment for aged patients is probably needed to predict the post-surgical outcome.

Sarcomatoid anaplastic carcinoma of the small bowel in cardiac transplant bearer.

Sarcomatoid carcinoma is a rare form of primitive carcinoma of the small bowel; it is considered a variant of adenocarcinoma, histologically characterized by a typical biphasic pattern with epithelial- and mesenchymal-like cells. Twenty-one cases have been described in the literature, presenting as small bowel obstructions (twenty cases) or superior vena cava syndrome (one case). The authors report the case of a 56 year-old man on immunosuppressive therapy for a heart transplant, who underwent surgery after a history of repeated episodes of melena, anemization and bowel obstruction. The operation brought to light an intraluminal occlusive mass in the distal ileum, associated with other intraluminal neoplasms of different sizes throughout the small bowel. No evidence of mesenteric adenopathies or hepatic metastases were found. Histological examination and immunohistochemical stain showed an anaplastic sarcomatoid carcinoma. The tumor cells showed strong positivity for cytokeratin and vimentin, and negativity for CD117 and CD34, as well as for all other characteristic markers of mesenchymal tumors. Early diagnosis is usually very difficult, due to the lack of any stereotyped clinical expression and the difficult to study the small bowel. Small-bowel barium follow-through or video capsule endoscopy can be helpful. In most cases, an emergency surgical operation is performed without a clear preoperative diagnosis. The case report is completed by a review of the literature.

Fitz-Hugh-Curtis-syndrome mimicking acute cholecystitis: value of new ultrasound findings in the differential diagnosis.

Fitz-Hugh-Curtis is a rare syndrome characterised by perihepatitis following pelvic inflammatory disease. We report the case of a patient with a right ovarian teratoma, abnormal liver tests and pain in the right abdomen and shoulder, initially attributed to an acalculous cholecystitis. Before gynaecological surgery, a repeat ultrasound scan found several small avascular peritoneal masses at the upper dome of the liver, not reported in the initial examination. This prompted laparoscopic exploration of the subdiaphragmatic space, and the final diagnosis of Fitz-Hugh-Curtis-syndrome was made. Such ultrasound finding appears to be a new diagnostic feature of this syndrome.